Mock Patient Scripts – Chest Pain

“It feels like something is pressing on my chest…”

Chest pain is one of the most common and high-stakes complaints in both emergency and primary care settings. While acute coronary syndrome (ACS) must always be ruled out, other conditions—such as pulmonary embolism, pericarditis, gastroesophageal reflux, and costochondritis—can present similarly. A skillful history and focused physical exam are essential to narrow the differential.

This article provides four realistic mock scenarios to help you practice English-based consultations, clinical reasoning, and OSCE/OET interview skills. Whether your patient says, “It hurts when I breathe” or “It’s not my heart, but the pain is still here,” you’ll learn how to think and speak like a confident clinician.

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🔎 Symptom-based Approach

🩺 Want a full overview of how to approach chest pain in clinical practice?
👉 Check out our comprehensive guide:
poohmedical.com/en-symptom-approach-chest-pain

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🩺 Case 1 – “I feel this squeezing pressure in my chest whenever I walk.”

🚪 Doorway Information

• Age/Gender: 62-year-old male
• Chief Complaint: Chest tightness with exertion
• Vital Signs: T 36.8°C / HR 78 / BP 142/88 / RR 16 / SpO₂ 97% RA

🗣️ Structured History

• Opening: “I’ve been getting this pressure in my chest whenever I walk uphill.”
• Shoreline: For the past two weeks, the patient has noticed chest discomfort during exertion, especially when climbing stairs or walking briskly. No symptoms at rest. He came in today because it has become more frequent and occurs with lighter activity.
• Onset & Course: Started 2 weeks ago, slowly progressive. Each episode lasts 5–10 minutes, relieved with rest.
• Associated Symptoms: Mild shortness of breath, no palpitations, syncope, or nausea. No radiation to arms or jaw.
• Mood / Function / Appetite / Sleep: Feels slightly anxious about the symptoms. Eating and sleeping normally.
• Medical History / Medication: Hypertension, hyperlipidemia. Meds: amlodipine, atorvastatin.
• Family & Social History (PAM HITS FOSS):
  • P: No diabetes or prior MI
  • A: NKDA
  • M: As above
  • H: No hospitalizations
  • I/T/S: None
  • F: Father died of MI at 59
  • O: N/A
  • S: Married, retired accountant. Ex-smoker (quit 10 years ago), no alcohol
• Concerns & Questions: “Could this be my heart? My dad had a heart attack around my age.”

🩺 Physical Examination

• Positive findings: None
• Important negative findings: No chest wall tenderness, lungs clear, heart sounds normal with no murmurs or gallops
• HEENT: Normal
• Chest: Clear breath sounds bilaterally
• CV: Regular rhythm, no murmurs
• Abdomen: Soft, NTND
• Extremities: No edema
• Neuro: Grossly intact

🧠 Differential Diagnosis (Top 3)

1. Stable Angina (most likely)
   • ✔︎ Exertional chest pressure relieved by rest
   • ✔︎ Cardiac risk factors (HTN, hyperlipidemia, FHx of MI)
   • ✖︎ No pain at rest, no ECG changes (yet)
2. Gastroesophageal reflux disease (GERD)
   • ✔︎ Can mimic angina
   • ✖︎ No relationship to food, no heartburn symptoms
3. Musculoskeletal pain (costosternal strain)
   • ✔︎ Chest wall is non-tender
   • ✖︎ No movement-related worsening

🩺 Clinical Reflection

His presentation is quite classic for stable angina. I’m concerned this could progress if left unaddressed. We need objective testing and risk stratification.

💡 Clinical Pearls

• Always ask about exertional triggers and relief with rest—it’s key to diagnosing angina.
• Patients may not describe pain as “pain”—they often say “pressure” or “tightness.”
• Don’t rely on troponin alone; a normal ECG and troponin do not rule out stable CAD.
• Family history of premature CAD increases suspicion, even if the patient looks well.

❓ Challenging Questions

Q1: “Am I having a heart attack right now?”
A: “That’s an important concern. Based on your symptoms and stable vitals, it doesn’t look like a heart attack at the moment, but we do want to check further. We’ll run an ECG and possibly blood tests to be safe. You’re in the right place, and we’ll take good care of you.”

Q2: “Can I still go on my trip next week?”
A: “I understand you’re looking forward to it. Once we know more from your tests, we’ll be able to advise you properly. If this is angina, it’s important to stabilize things before travel. Let’s focus on diagnosis first, and then we can make a safe plan.”

📝 SOAP Note

S: 62-year-old man with 2-week history of exertional chest pressure, worse with uphill walking. No symptoms at rest. Mild SOB, no radiation or diaphoresis. Concerned due to family history of MI.

O: T 36.8°C, HR 78, BP 142/88, RR 16, SpO₂ 97% RA. Normal heart sounds, no chest wall tenderness, lungs clear. No neuro deficits.

A:
# Exertional chest pressure
# Cardiac risk factors (HTN, hyperlipidemia, FHx)
# No pain at rest or abnormal physical findings

ddx): Stable angina, GERD, MSK chest pain  
r/o): ACS (no rest pain, no ECG yet), PE (no sudden onset or hypoxia)

→ Most likely stable angina. Need ECG and stress testing. Consider cardiology referral.

P:
- ECG
- Troponin x2
- Cardiology referral for stress test ± imaging
- Start low-dose aspirin and beta blocker if confirmed
- Lifestyle counseling and risk factor management

🫁 Case 2 – “It suddenly hurt when I took a deep breath.”

🚪 Doorway Information

• Age/Gender: 48-year-old female
• Chief Complaint: Sudden chest pain and shortness of breath
• Vital Signs: T 37.2°C / HR 110 / BP 102/64 / RR 24 / SpO₂ 91% RA

🗣️ Structured History

• Opening: “It started all of a sudden when I stood up from my chair.”
• Shoreline: The patient developed sudden sharp pain in the right chest and shortness of breath about 3 hours ago while working at her desk. She has not experienced anything like this before. She denies fever or cough.
• Onset & Course: Acute onset, non-radiating pleuritic pain. Has remained constant in intensity. No trauma.
• Associated Symptoms: Dyspnea, mild lightheadedness. No palpitations, hemoptysis, or leg swelling.
• Mood / Function / Appetite / Sleep: Anxious, difficulty concentrating due to discomfort. No change in appetite or sleep.
• Medical History / Medication: Recently returned from a 14-hour flight. Taking oral contraceptives. No known chronic illness.
• Family & Social History (PAM HITS FOSS):
  • P: No chronic illness or prior clots
  • A: NKDA
  • M: OCP
  • H/I/T/S: None
  • F: Mother had DVT after hip surgery
  • O: N/A
  • S: Office worker, non-smoker, minimal alcohol
• Concerns & Questions: “Could it be a heart attack? I’ve never had chest pain before.”

🩺 Physical Examination

• Positive findings: Tachycardia, mild hypoxia (SpO₂ 91%)
• Important negative findings: Clear lungs, normal heart sounds, no leg swelling or calf tenderness
• HEENT: Normal
• Chest: Normal breath sounds, no wheezing or rales
• CV: Regular tachycardia, no murmurs
• Abdomen: Soft, NTND
• Extremities: No edema, no tenderness or asymmetry
• Neuro: No focal deficits

🧠 Differential Diagnosis (Top 3)

1. Pulmonary Embolism (most likely)
   • ✔︎ Sudden pleuritic chest pain with dyspnea and mild hypoxia
   • ✔︎ Risk factors: long-haul flight, OCP, family history of DVT
   • ✖︎ No leg swelling or hemoptysis
2. Pneumothorax
   • ✔︎ Sudden pleuritic chest pain
   • ✖︎ No decreased breath sounds or hyperresonance
3. Anxiety-related hyperventilation
   • ✔︎ Common mimic
   • ✖︎ Doesn’t fully explain hypoxia or sudden onset

🩺 Clinical Reflection

This is a classic intermediate-risk PE presentation—sudden pleuritic chest pain with mild hypoxia in the context of recent immobility and estrogen use. Immediate diagnostic imaging is needed.

💡 Clinical Pearls

• Always ask about recent travel, surgery, immobility, or estrogen use in cases of chest pain.
• Normal physical exam does not rule out PE—look at the whole picture.
• PE may present subtly, especially in young, otherwise healthy individuals.
• Use the Wells score or PERC rule to guide further testing.

❓ Challenging Questions

Q1: “Can you tell me for sure what this is?”
A: “I understand you want clarity. Based on your symptoms and risk factors, a blood clot in your lung is possible. We’ll need imaging to confirm it. We’re acting quickly to find the cause and start treatment if needed.”

Q2: “Am I going to die from this?”
A: “It’s natural to feel scared. The good news is you’re in the right place and we’re acting fast. If this is a clot, we have effective treatments. You’re not alone—we’ll monitor you closely and get you the care you need.”

📝 SOAP Note

S: 48F presents with sudden pleuritic right chest pain and SOB starting 3h ago. No trauma, cough, or fever. Returned from 14h flight 2 days ago. On OCPs. No leg symptoms.

O: T 37.2°C, HR 110, BP 102/64, RR 24, SpO₂ 91% RA. No wheezes or crackles. Tachycardic, no edema or leg tenderness.

A:
# Sudden pleuritic chest pain
# Mild hypoxia and tachycardia
# Risk factors: long flight, OCP, FHx of DVT

ddx): PE, pneumothorax, anxiety-related pain  
r/o): ACS (no radiation or typical pattern), pneumonia (no fever or sputum)

→ Intermediate-risk PE suspected. Proceed with labs and imaging.

P:
- D-dimer (if low/intermediate risk)
- CT pulmonary angiography (CTPA)
- Cardiac enzymes and ECG
- Supplemental O₂ as needed
- Consider anticoagulation after imaging

🦴 Case 3 – “They said it wasn’t my heart, but the pain is still here.”

🚪 Doorway Information

• Age/Gender: 36-year-old male
• Chief Complaint: Persistent chest pain for 1 week
• Vital Signs: T 36.9°C / HR 74 / BP 126/78 / RR 14 / SpO₂ 98% RA

🗣️ Structured History

• Opening: “The ER told me it’s not my heart, but it still hurts when I move.”
• Shoreline: The patient developed localized left-sided chest pain a week ago after lifting a heavy suitcase. He visited the ER, where cardiac workup was negative. The pain continues but hasn’t worsened.
• Onset & Course: Gradual onset, non-radiating. Pain is sharp and worsens with movement and deep inspiration. No clear progression.
• Associated Symptoms: No dyspnea, cough, or palpitations. No nausea or diaphoresis.
• Mood / Function / Appetite / Sleep: Frustrated and worried. Eating and sleeping normally but avoids exercise due to pain.
• Medical History / Medication: Generally healthy. No regular medications. Takes occasional ibuprofen.
• Family & Social History (PAM HITS FOSS):
  • P: No chronic conditions
  • A: NKDA
  • M: NSAIDs PRN
  • H/I/T/S: None
  • F: Non-contributory
  • O: N/A
  • S: Office worker, non-smoker, moderate alcohol on weekends
• Concerns & Questions: “If it’s not my heart, then what is causing this?”

🩺 Physical Examination

• Positive findings: Reproducible pain on palpation of left 4th–5th costochondral junction
• Important negative findings: Lungs clear, heart sounds normal, no signs of pleural effusion or infection
• HEENT: Normal
• Chest: No swelling or skin changes
• CV: Normal S1S2, no murmurs
• Abdomen: Soft, NTND
• Extremities: Normal
• Neuro: Normal

🧠 Differential Diagnosis (Top 3)

1. Costochondritis (most likely)
   • ✔︎ Localized chest pain with tenderness and mechanical component
   • ✔︎ Cardiac causes already ruled out
   • ✖︎ None
2. Muscle strain
   • ✔︎ Triggered by lifting activity
   • ✖︎ No muscle bruising or back/shoulder involvement
3. Pleuritis
   • ✔︎ Pleuritic pattern possible
   • ✖︎ No respiratory symptoms, fever, or auscultation findings

🩺 Clinical Reflection

Reproducible chest pain after mechanical strain, with a negative cardiac workup and localized tenderness, strongly suggests costochondritis. Patient reassurance and conservative management are key.

💡 Clinical Pearls

• Always palpate the chest wall when evaluating chest pain—it can reveal non-cardiac causes.
• Costochondritis can last for days to weeks; patients often need reassurance and NSAID guidance.
• “It’s not your heart” may not be enough—explain what the actual cause likely is.
• Distinguish from Tietze syndrome (which includes swelling).

❓ Challenging Questions

Q1: “Why does it still hurt even after my heart tests were fine?”
A: “That’s a good question. Your heart is fine, but the pain is coming from the joints where your ribs meet your chest bone. It’s called costochondritis and it can linger for days or weeks. The good news is it’s not dangerous, and it often improves with rest and medication.”

Q2: “Do I need more tests?”
A: “Based on your previous ER tests and today’s findings, no further tests are needed right now. Your pain matches a musculoskeletal cause. But we’ll keep monitoring—if anything changes, we’ll reassess quickly.”

📝 SOAP Note

S: 36M with 1-week history of localized left chest pain after lifting luggage. Sharp, worse with movement and deep breath. Cardiac workup negative at ER. No SOB or systemic symptoms.

O: T 36.9°C, HR 74, BP 126/78, RR 14, SpO₂ 98% RA. Tenderness over left 4–5th costochondral area. No abnormal heart/lung sounds.

A:
# Localized pleuritic chest pain
# Reproducible tenderness over chest wall
# Negative prior cardiac workup

ddx): Costochondritis, muscle strain, pleuritis  
r/o): ACS (ruled out by prior ER visit), pneumonia (no cough/fever), PE (no dyspnea or risk factors)

→ Likely costochondritis. Conservative management appropriate.

P:
- NSAIDs for pain
- Reassurance and education
- Avoid strenuous activity
- Follow-up if worsening or no improvement in 1 week

❤️ Case 4 – “It hurts more when I lie down flat.”

🚪 Doorway Information

• Age/Gender: 27-year-old male
• Chief Complaint: Chest pain worsening when lying down
• Vital Signs: T 37.8°C / HR 98 / BP 118/72 / RR 18 / SpO₂ 98% RA

🗣️ Structured History

• Opening: “The pain gets worse when I lie on my back, but it feels a bit better when I sit up.”
• Shoreline: Chest pain began 3 days ago, gradually worsening. It is sharp and central, worsens when lying down or taking deep breaths. He finds relief when leaning forward.
• Onset & Course: Gradual onset. Constant dull ache with intermittent sharp episodes. No known trigger.
• Associated Symptoms: Mild fever and fatigue. No cough, dyspnea, or palpitations. No leg swelling or recent trauma.
• Mood / Function / Appetite / Sleep: Slight fatigue, decreased appetite. Sleep disturbed by discomfort.
• Medical History / Medication: Had a cold about 2 weeks ago. Not on any regular medications.
• Family & Social History (PAM HITS FOSS):
  • P: Generally healthy, no cardiac history
  • A: NKDA
  • M: None
  • H/I/T/S: None
  • F: Non-contributory
  • O: N/A
  • S: Student, non-smoker, no alcohol or drug use
• Concerns & Questions: “Could this be something serious like heart inflammation?”

🩺 Physical Examination

• Positive findings: Pericardial friction rub on auscultation
• Important negative findings: Lungs clear, no JVD or edema, vitals stable
• HEENT: Normal
• Chest: Clear lungs bilaterally
• CV: Friction rub present, normal rhythm, no murmurs
• Abdomen: Soft, NTND
• Extremities: No swelling
• Neuro: Normal

🧠 Differential Diagnosis (Top 3)

1. Acute Pericarditis (most likely)
   • ✔︎ Positional, pleuritic chest pain
   • ✔︎ Pericardial friction rub and recent viral illness
   • ✖︎ No ECG or imaging yet to confirm
2. Pleuritis
   • ✔︎ Pleuritic chest pain with viral prodrome
   • ✖︎ No focal lung findings or productive cough
3. GERD
   • ✔︎ Possible mimic, especially with positional pain
   • ✖︎ No acid symptoms or GI history

🩺 Clinical Reflection

Classic presentation of pericarditis with positional pain, viral prodrome, and friction rub. Must confirm with ECG and monitor for pericardial effusion or tamponade.

💡 Clinical Pearls

• Pericardial pain often improves when sitting up or leaning forward—ask about this specifically.
• Don’t miss the pericardial friction rub—it’s fleeting but pathognomonic.
• Most cases are viral and self-limited, but monitor for effusion or tamponade.
• EKG shows diffuse ST elevation and PR depression in pericarditis.

❓ Challenging Questions

Q1: “Could this be a heart attack?”
A: “It’s understandable to worry about that. Your symptoms and exam point to inflammation around the heart rather than a blockage. We’ll do an ECG and labs to confirm. Thankfully, this condition is usually treatable with medication.”

Q2: “Do I need to be admitted to the hospital?”
A: “That depends on what we find on your ECG and tests. If it’s mild, you may go home with treatment and follow-up. But if there’s any sign of fluid around the heart, we may need to observe you more closely.”

📝 SOAP Note

S: 27M with 3-day history of sharp chest pain worse with lying down and deep inspiration. Some relief when sitting forward. Mild fever and recent URI. No dyspnea or leg swelling.

O: T 37.8°C, HR 98, BP 118/72, RR 18, SpO₂ 98% RA. Pericardial friction rub present. Lungs clear, no JVD or edema.

A:
# Positional, pleuritic chest pain
# Pericardial friction rub
# Recent viral infection

ddx): Pericarditis, pleuritis, GERD  
r/o): ACS (young, atypical), PE (no dyspnea, hypoxia)

→ Likely acute pericarditis. Need ECG to confirm. Monitor for effusion.

P:
- ECG
- Cardiac enzymes
- CRP, CBC
- Echocardiography
- Start NSAIDs and colchicine
- Monitor for effusion or signs of tamponade

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🧭 Summary & Clinical Takeaways

Chest pain demands a structured and efficient approach to rule out life-threatening conditions such as acute coronary syndrome (ACS), pulmonary embolism, and aortic dissection. At the same time, it’s important not to overlook common benign causes such as musculoskeletal pain or GERD, especially in younger or low-risk patients.

This article has explored four realistic scenarios to help you practice distinguishing between high- and low-risk presentations, sharpen your clinical reasoning, and respond to patients’ fears and questions in natural English.

🧠 VITAMIN CDE-based Differentials for Chest Pain

Use the VITAMIN CDE framework to systematically consider different causes of chest pain:

• V – Vascular: Acute coronary syndrome (ACS), Aortic dissection, Pulmonary embolism
• I – Infectious: Pericarditis, Pneumonia, Pleuritis
• T – Trauma: Rib fracture, Muscle strain, Costochondritis
• A – Autoimmune: Systemic lupus erythematosus (serositis), Rheumatic fever (carditis)
• M – Metabolic: Severe anemia or thyrotoxicosis causing angina-like symptoms
• I – Idiopathic: Idiopathic pericarditis, Functional chest pain
• N – Neoplastic: Mediastinal tumors, Lung cancer invading pleura
• C – Congenital: Mitral valve prolapse, Hypertrophic cardiomyopathy
• D – Degenerative: Osteoarthritis of the thoracic spine (rare), Cervical radiculopathy
• E – Endocrine / Psychogenic: Panic attacks, Anxiety-related hyperventilation, GERD

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🔗 Related Articles

• Symptom-Based Approach to Chest Pain
• Symptom-Based Approach to Dyspnea
• Symptom-Based Approach to Palpitations
• Mock Patient Scripts Top

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📚 References

• Uptodate: Evaluation of the adult with chest pain in the emergency department
• Mayo Clinic – Chest pain: First aid and differential
• BMJ Best Practice – Acute pericarditis

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🎓 Recommended Resources

• First Aid for the USMLE Step 2 CS – Cases and communication strategies
• OET Preparation Guide – Role-play based English for healthcare professionals
• Clinical Reasoning 101 by Dr. Tierney – Mastering differential diagnosis

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